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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294256
Report Date: 02/04/2021
Date Signed: 02/04/2021 11:41:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EASTRIDGE RESIDENTIAL CARE HOMEFACILITY NUMBER:
435294256
ADMINISTRATOR:MARY ROSE BAQUIRANFACILITY TYPE:
740
ADDRESS:2690 KEPPLER DRIVETELEPHONE:
(408) 799-0502
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 5DATE:
02/04/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maryrose BaquiranTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance (TA) tele-visit with Program Clinical Consultant (PCC) Paul Portem, RN today. LPA and PCC met with Administrator Maryrose Baquiran.

At 10:11 AM, a video tour of the facility was conducted. The facility's current census is 5. 2 out of 5 residents are currently admitted to an acute care facility. 1 out of 3 residents in the facility is under COVID-19 isolation. Isolation room was observed with closed door and marked with warning posters. COVID-19 information and guide posters were observed by the entrance and common areas of the facility. Hand hygiene supplies and personal protective equipment (PPE) supplies were observed available in the premises. The facility has screening procedures in place for all essential visitors.

Based on today's facility tour, the following recommendations were provided:

1. Facility shall place a covered trash bin both inside and outside the isolation room.
2. Facility shall place hand towels in a dispenser to protect from contamination.
3. Facility shall use disinfectants listed under List N by the US Environmental Protection Agency (EPA) www.epa.gov as effective against the COVID-19 virus. Facility to follow manufacturer's instructions for use including dilution and wet times.
4. Facility to continue surveillance testing for all COVID-19 negative staff.
5. The facility has a COVID-19 vaccination schedule confirmed with CVS - 01/25/21, 02/15/21, and 03/08/21. Facility shall continue to follow COVID-19 mitigation plan, as necessary, even after vaccination.

No deficiencies were cited today. A copy of this report was provided to Administrator via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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